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Robert Myers, Ph.D., Associate Clinical Professor of Psychiatry and Human Behavior at UC Irvine School of Medicine and Clinical Consultant at the Brand New Day Program, presented this workshop. It was divided into three parts. In the first part, he spoke about the increased risks psychiatric patients faced for other illnesses, and the ways that these shorten the average lifespan of a person living with mental illness. In the second part, he offered advice of things that you can do to make sure that your own medical and psychiatric care are integrated. In the third part, he described what Brand New Day does, in its specialized insurance program for psychiatric patients, to ensure integrated care, with better outcomes and cost savings. This involves a Medical Home Model, Care Partners, and a Circle of Support.

The average life expectancy in the Unites States is 78 years. The average life expectancy for people who are seriously mentally ill is 53 to 57 years. This is the biggest lifespan disparity in the US, bigger than any lifespan disparity for gender, race, or social class. There are six major causes of this increased risk.

Psychiatric patients have 3.4x the cardiovascular risk of non-psychiatric patients.

70% of people with serious mental illness have another chronic health problem, usually a pulmonary problem or diabetes. 50% have two or more chronic problems. 42% have problems severe enough to limit function.

Psychiatric patients have higher rates of modifiable risk factors: smoking, alcohol consumption, poor nutrition, obesity, lack of exercise, “unsafe” sexual behavior, and IV drug use. They are more likely to reside in group care facilities or homeless shelters, where they have more exposure to tuberculosis and other infectious diseases and less opportunity to modify individual nutrition practices. Medications, which are necessary for psychiatric health, can cause overweight and obesity, insulin resistance, diabetes, and abnormal lipid panels.

75% of psychiatric patients with severe mental illness are tobacco dependent, with a 2-4x higher smoking rate than the general population. Most mentally ill people smoke and die of smoking-related illnesses. 27% of consumer income (“consumer” is the word used at this mental health conference for psychiatric patients) went to cigarettes. 22% started smoking in a psychiatric setting.

Obesity is more prevalent, 1.2-1.8x higher in people with depression, 1.5-2.3x higher in people with bipolar disorder, and 3.5x higher in people with schizophrenia.

Psychiatric patients have poor access to health care. They have limited income, lack preventive care, and overuse emergency and specialized care. They have lower rates of primary care and routine testing, little integration between primary and psychiatric care, poor motivation to seek care, and fragmented and inconsistent care.

The goals of integration: Improve patient adherence and self-management, decrease over or under utilization, reduce health risk behaviors and increase health enhancing behavior, and monitor and improve patient outcomes. A Medical Home, interdisciplinary teams, disease management programs like those that insurance programs provide for asthma and diabetes, and family/caregiver involvement can all help with integration.

Some things you can do to improve your healthcare integration:

Sign to let your primary care physician and psychiatrist exchange information in writing and over the phone.

Use only one pharmacy for your prescriptions. Ask the pharmacist to check for drug interactions.

Use a pharmacy that has online access for patients, so you can print out a medication list to take to each of your doctors.

Use only one laboratory, such as Quest, and give access to all of your doctors, so they can see all of your lab results.

Steps to make the most use of your doctor’s visit:

Plan ahead: Plan what to tell your doctor, and write a list of your questions.

Exchange information, and ask if you don’t understand or need more information.

Participate: Discuss different ways of handling side effects, and let your doctor know about any vitamins, etc. that you may be taking. [LG: Here I note, as a cancer survivor, that oncologists are very explicit about needing to be informed about everything you are taking, including OTC medications and vitamins.]

Agree on a treatment plan.

Repeat back to your doctor your understanding of your plan.

Three things you can do for your health:

Ask your primary care physician for a standard list of preventive care appointments needed for people of your sex and age.

If you are a smoker, ask your primary care physician for a referral to a stop smoking program. (California has a good one, No Butts.)

Keep active. Go for walks. Join a gym. Check out the Recreation and Parks Department, adult school, and your local community college. Ride the bus to get around. Walking 30 minutes 5x a week will make everyone healthier.

How Brand New Day integrates care:

Everyone gets a Client and Personal Services Coordinator/Life Coach. For people with mental illness, the psychiatrist is the primary treating physician. Everyone also has a primary care physician. There are Field Intervention Nurses who do home visits, a Clinical Program Director, a Life Coach, and specialized pharmacies.

The primary treating physician is the psychiatrist providing direct care and direct access. The psychiatrist talks to the PCP and the life coach, and is involved in any hospitalization, whether a behavioral health hospitalization or a medical hospitalization.

Each patient gets a PCP with experience with this population, who works with the psychiatrist and the life coach, and provides annual physicals and preventive care.

The Life Coach is key, and is assigned to every member on enrollment, to bond and win the trust of the member, assist in services, monitor compliance, and advocate for the member.

A Field Intervention Nurse, post-discharge, will do home safety inspections, give shots for diabetes, etc. 10% of their population get their psychiatric medications in the form of long term injectables. 80% of their psychiatric bed days are for people who have been with them for a year or less, so their program has good success in reducing the need for hospitalization.

The Life Coach/Case Manager may have a BA in psychology, an LCSW, etc.

Pharmacies: They work with pharmacies that do bubble pack and delivery, on-line checks of drug interactions, etc.

Board and care is cheaper than the hospital. They supply incentives to take meds, in the form of gift cards. Contingency management and token economies induce compliance on meds and sobriety. They have been doing this since 2000.

A Wellness/Activities Center provides arts and crafts, yoga, music, basketball, a computer lab, vocational assistance, etc. It serves both as a place for partial hospitalization and as a clubhouse for those who are stable, and is also a place where you can meet your case manager. Sometimes they take the program to board and care homes and adult daycare.

They supply free bus passes, free gym memberships, free lunch days, and field trips. There is mental health education improvement, such as Goal Setting, Anger Management, and Stress Management. There are also Disease Management Programs available for more than a dozen illnesses, such as diabetes, hypertension, etc.

Brand New Day has the best dental care benefit available for this population.

They have been able to get their population to do flu shots, colonoscopies, etc. (they got a five star rating on their ability to get people to do colonoscopy screening).

Outcomes: Milliman found that Brand New Day had 37% lower medical hospitalization and 46% lower psychiatric hospitalization than fee for service. They saved the state $3 million dollars. They reduced long term care and pregnancy complications. They get the same money that everyone else gets.

For the gym memberships, they have a group contract with LA Fitness, and will pay for a membership as long as you go.

Contact information: (866)255-4795, http://brandnewdayhmo.com

They are Medicare approved.

There is a hole in coverage for this population: Schizophrenia hits people who are 18-25, who don’t have 40 quarters yet to qualify for Medi-Medi, and Medi-Cal is underfunded. [LG: I guess that’s why the first talk reported how the Medi-Cal expansion helps this population.]

2 Responses to “Meeting of the Minds, 2013: Integration of Mental Health and Primary Care”

I assume the figures on life expectancy for people with mental health problems correlate closely with life expectancy for homeless people (according to one doctor I know, that works out to “age 60 or ten years on the street, whichever comes first.” I don’t know the official stats.)

I, too, would expect a correlation between the figures on life expectancy for people with mental health problems and life expectancy for homeless people. I remember that when I volunteered at a ministry that served homeless people, many of the people who came to our drop in center struggled with mental illness. The talk, though, didn’t say anything about such a correlation one way or the other.